Shoulder ligaments tear are ruptures of the ligament structures located there, which contribute to the stability of the joint. Depending on the severity of the injury, one or more ligaments may be affected.
Causes of shoulder ligaments tear
Tearing of the ligament structures often occurs during a fall with direct force applied to the shoulder joint and when the arm is extended.
The resulting leverage effect can lead to various joint injuries of the shoulder girdle. Tearing of the ligaments is not inevitable, but may also be due to overstretching or entrapment.
Symptoms of shoulder ligaments tear
A fracture of the acromioclavicular joint usually causes direct pain. This occurs both at rest and under stress.
The area around the shoulder joint can swell. Depending on the extent of the injury, the collarbone shifts upwards and can then already be seen from the outside. During the clinical examination, patients often report a pressure pain. The collarbone is also movable and can be pressed down like a piano key.
What is the severity of shoulder ligaments tear?
Classification according to Tossy
Depending on the extent of the injury, these can be divided into three forms. The classification, according to Tossy, is widespread in everyday clinical practice.
Tossy I is an overstretching or stretching of the two ligament structures mentioned.
In Tossy II, on the other hand, there is a rupture of the acromioclavicular ligament and overstretching of the coracoclavicular ligament. This instability leads to an incomplete dislocation (subluxation) of the acromioclavicular joint.
The joint head is still partially located in the leading joint capsule.
In Tossy III, both ligaments are finally torn, and the shoulder joint is no longer secured by the strong ligament structures. This is a complete dislocation (luxation) of the acromioclavicular joint.
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Classification by Rockwood
This classification distinguishes six types of injury.
Type 1 involves a stretching of the acromioclavicular ligament, and the patient feels a slight pain in pressure and movement.
In type 2, there is a rupture of this ligament and a slight incomplete dislocation of the lateral clavicular fragment.
Type 3 describes a rupture of the acromioclavicular and coracoclavicular ligament. Besides, a step formation between acromion and clavicle can be seen.
Type 4 shows the same injuries as type 3, but the clavicle is displaced backward. The clavicle can run in or even through the trapezius muscle. It can be palpated in the area of the shoulder blade.
In type 5, there is a clear distance between the clavicle and the shoulder blade.
There is no longer any grip so that the shoulder sinks downwards while the clavicle escapes upwards. Often there is also a rupture of the trapezius and deltoideus muscles.
Type 6 is a severe displacement of the torn clavicle under the acromion or shoulder blade protrusion (proc. coracoideus).
In most cases, this injury is accompanied by rib fractures, clavicula fractures, and injuries to the nerve plexus lying there.
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Therapy of shoulder ligaments tear
The ligament injuries, according to Tossy, I, and II, can be treated conservatively, i.e., without surgery. The treatment includes a six-week immobilization of the joint with a Gilchrist bandage.
The immobilization reduces the tension on the joint caused by the body’s weight. This allows the ligament structures to adapt and heal entirely on their own.
To alleviate the pain, an additional painkiller can be prescribed. Physiotherapy can support the healing process and avoids the development of contractures.
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Tapering in case of torn ligament
Minor injuries such as overstretching or strains to the ligament structures of the shoulder can be treated with Kinesio tapes.
With the correct application technique, the tape has a supporting and stabilizing effect on the acromioclavicular joint. The tapes are often applied in the shoulder area along the longitudinal course of the deltoid muscle.
The tape is split in the middle for this purpose. The lower continuous part is attached to the lower end of the deltoid muscle. Now one half of the tape is stuck along the front edge of the muscle, the other half along the rear edge. Finally, the tape encloses the muscle.
This relieves the injured ligament structures or supports them during movement. After a longer period of rest, the ligaments can also be applied for protection when resuming sports activities.
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Tossy III or Rockwood types 3, 5, and 6 injuries require surgery for the first 12 days due to their instability. There is an indication for surgery, especially in younger patients with stress in everyday life and at work.
Also, the protruding collarbone is felt to be disturbing and should be reduced.
In the meantime, operations on the shoulder joint are performed arthroscopically. An endoscope is inserted through a longitudinal incision of about 3 cm above the acromion, which makes the inside of the joint visible to the surgeon. Finally, the clavicle can be reattached using appropriate instruments.
Depending on the surgical method, wires, screws, or artificial bands are available to fix the clavicle to the cortex.
The anatomical structures are thus returned to their original position, and the shoulder joint is stable again after healing. This minimally invasive procedure takes about 2 hours or longer, depending on the severity of the injury.
If a shoulder joint replacement has been inadequately treated, chronic instability can develop in the shoulder joint. This complication can also be treated surgically by using a tendon transplant made from the patient’s body material. Tendons from the knee flexor area, such as the semitendinosus tendon, are used for this purpose.
The transplant is placed through a drilled hole between the coracoid process and the bowl bone. The body’s tissue replaces the previously unstable connecting ligament there.
Often this operation leads to a significantly better securing of the acromioclavicular joint, and the load can be increased again.
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Aftercare of a torn ligament at the shoulder
After the operation, immobilization with a Gilchrist dressing is prescribed. The duration depends on the surgeon’s instructions and is between 4 and 8 weeks. During this time, the ligament structures have the opportunity to adapt and heal.
Physiotherapy can be prescribed to support the healing process. This involves movement exercises in the wrist and elbow joint to avoid complications.
Nevertheless, complete healing is a long process, so that many patients still struggle with residual symptoms 3-6 months after the operation. The duration of healing also depends on the severity of the injury, but also the age and general condition of the patient.
What are the complications of torn ligaments in the shoulder?
Complications include recurrent pain and the development of chronic instability despite surgery. Often, a new operation with a tendon transplant must then be considered.
Furthermore, arthrosis can develop due to poorer healing. Calcifications in the shoulder can also occur. The consequences are restricted mobility and increasing abrasion of the protective cartilage substance. In the longer term, the complications, in turn, lead to increasing instability in the acromioclavicular joint.
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Diagnosis of shoulder ligaments tear
In addition to the anamnesis of the accident and a clinical examination, the X-ray ensures the diagnosis of a torn ligament and shows the extent of the injury.
During the examination by the doctor, the “piano touch phenomenon” is often observed in a Tossy III injury. Due to the rupture of both ligaments, the clavicle protrudes very far upwards and can be pressed down like piano keys and then jump up again.
X-rays of the shoulder joint are taken in 2 planes.
In the images obtained, one finally sees a clear widening of the joint space and mostly a displacement of the clavicle.
Besides, X-rays can be taken under stress to confirm the diagnosis. The patient holds a 20-30 lb load on the affected arm. The x-ray image then shows a clear protrusion of the lateral clavicle end.
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Duration of shoulder ligaments tear
More severe ligament ruptures (Rockwood IV-VI and III in young patients) are treated surgically using various techniques. It is expected to take 3-4 months until the shoulder is fully able to bear weight again. Strong and excessive strain during sports and work should not be resumed before six months.
In general, it cannot be assumed that the patient is unable to work. In the first few weeks, however, a sick note can be issued by the doctor treating the patient. For the time after that, it may be necessary to discuss with the employer whether other possibilities of employment in the work process are possible.
The healing time can vary greatly and depends on the size of the injury, the patient’s cooperation, and the fitness level of the shoulder. If a patient has pronounced musculature and was active in sports before the torn ligament, faster healing can be assumed. However, renewed torn ligaments are quite possible. Therefore, patients should strengthen their shoulders permanently with their exercises and thus prevent further problems.
Torn ligaments that are less severe (Rockwood I-III: overstretching and partial tears) are treated conservatively.
Structure of the shoulder joint
The shoulder consists of several joints. In addition to the actual ball joint, there is also the acromioclavicular joint. It is formed by the end of the collarbone and a part of the shoulder roof, the so-called acromion.
In medical terminology, this joint is called the acromioclavicular joint. It is surrounded by a strong joint capsule and is secured from above, below, front and back by thick ligament structures.
The acromioclavicular ligament is located between the acromion and the clavicle, and the coracoclavicular ligament is located between the coracoabral process, a projection of the shoulder blade to the front, and the clavicle.
The latter takes over about 80% of the strength of the shoulder joint, which shows how important these ligaments are for optimal movement in the shoulder area.
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